Introduction

Front. Psychiatry

Frontiers in Psychiatry

Front. Psychiatry

1664-0640

Frontiers Media S.A.

10.3389/fpsyt.2024.1397102

Psychiatry

Perspective

Educating the next generation of psychiatrists in the use of clinical neuromodulation therapies: what should all psychiatry residents know?

Menon

Sahit N.

¹ ^* Torrico

Tyler

¹ Luber

Bruce

¹ Gindoff

Brian

¹ Cullins

Lisa

² Regenold

William

¹ Lisanby

Sarah H.

¹ Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, United States ² Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, United States

Edited by: Albino J. Oliveira-Maia, Champalimaud Foundation, Portugal

Reviewed by: Emmanuel Poulet, INSERM U1028 Centre de Recherche en Neurosciences de Lyon, France

Fabiana Ventura, Coimbra Hospital and University Center, Portugal

*Correspondence: Sahit N. Menon, sahitmenon@ucsd.edu

15 05 2024

2024

1397102

06 03 2024 30 04 2024

2024

Menon, Torrico, Luber, Gindoff, Cullins, Regenold and Lisanby

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

A variety of neuromodulation treatments are available today and more are on the way, but are tomorrow’s psychiatrists prepared to incorporate these tools into their patients’ care plans? This article addresses the need for training in clinical neuromodulation for general psychiatry trainees. To ensure patient access to neuromodulation treatments, we believe that general psychiatrists should receive adequate education in a spectrum of neuromodulation modalities to identify potential candidates and integrate neuromodulation into their multidisciplinary care plans. We propose curricular development across the four FDA-cleared modalities currently available in psychiatric practice: electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). With a focus on psychiatry residency training, the article delineates core learning components for each neuromodulation technique. For each modality, we review the clinical training status, the respective FDA-cleared indications, mechanisms of action, clinical indications and contraindications, adverse effects, informed consent process, dosing considerations, and clinical management guidelines. The approach outlined in this article aims to contribute to the development of a well-rounded generation of psychiatry trainees with the capacity to navigate the growing field of neuromodulation. Whether or not a psychiatrist specializes in delivering neuromodulation therapies themselves, it is incumbent on all psychiatrists to be able to identify patients who should be referred to neuromodulation therapies, and to provide comprehensive patient care before, during and after clinical neuromodulation interventions to optimize outcomes and prevent relapse.

psychiatry residency neuromodulation TMS ECT DBS VNS

section-in-acceptance

Neurostimulation

1 Introduction

Neuromodulation interventions have long been a core part of psychiatric practice. For example, electroconvulsive therapy (ECT) has been in clinical use since the early 20^th Century. Today, these interventions have expanded to include transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS), each of which is cleared by the Food and Drug Administration (FDA) for the treatment of psychiatric disorders. As device-based therapies expand, future psychiatrists must be equipped to integrate these interventions into treatment plans.

Currently, the Accreditation Council for Graduate Medical Education (ACGME) guidelines on neuromodulation competencies in psychiatry residency consist of a single sentence: “indications for and uses of electroconvulsive and neuromodulation therapies (1).” This leaves training programs limited guidance on how to structure neuromodulation training in psychiatry residency.

While other articles discuss the potential role for a subspecialty in interventional psychiatry (2, 3), we focus on what every psychiatrist should know about neuromodulation therapies. We propose that knowledge in neuromodulation techniques should be integrated into general psychiatry residency. Having foundational knowledge of neuromodulation techniques in residency will equip psychiatry trainees with procedural knowledge, empower them to refer patients for neuromodulation when appropriate, and help them understand how to manage patients before, during and after neuromodulation interventions to sustain remission and to prevent relapse.

The 2010 American Psychiatric Association (APA) practice guidelines for treatment of major depressive disorder (MDD) in adults includes ECT and TMS as acute phase treatment modalities. VNS is cited as an option after inadequate response to at least four adequate trials of antidepressants, including ECT (4). In 2016, the Canadian Network for Mood and Anxiety Treatments (CANMAT), published clinical guidelines for management of adults with MDD, which includes ECT, TMS, DBS, VNS, magnetic seizure therapy (MST) and transcranial direct current stimulation (tDCS) (5). Aligning clinical practice with these guidelines requires that psychiatry residents receive neuromodulation training.

Research indicates that one potential barrier to neuromodulation access is inadequate medical education (6). Access to neuromodulation is limited by professionals trained to refer for, prescribe, and administer these modalities. Research has shown that in the inpatient setting, ECT recipients were more likely to be female and white-non-Hispanic (7, 8). Furthermore, Noorani et al. showed that 29% of ECT providers in the US are female, and only 1% are Black or African American (9). Clinician biases may be a potential source of ECT disparities among patients of color (10). In healthcare, medical bias, or the tendency for physicians to make decisions on the basis of prejudice or stereotypes, can lead to lower quality of care (11). To address this issue, training programs can integrate culturally informed treatment strategies that acknowledge how certain practices lead to poor mental health outcomes among minoritized ethnic groups (12). Additional work has shown that ECT is not provided as an inpatient procedure in 9 out of 10 hospitals (13), which may relate to unfamiliarity with the technique and negative attitudes towards ECT. This highlights the importance of early ECT training in psychiatry residency. Other barriers to initiating ECT include lack of well-trained colleagues and ECT practitioners (14). Prior studies have suggested that observing ECT generally reduces negative attitudes (15), which could translate to improved patient access.

Additionally, a survey-based study on psychiatrists’ attitudes towards TMS found that psychiatrists who lacked formal TMS training did not know the indications for referring a patient with depression, and only 1 in 4 knew how to properly refer (16). Patient safety is linked to provider training, as the risk-to-benefit ratio of TMS varies for each individual (17). These findings highlight the importance of TMS education in relation to patient care.

Established guidelines on neuromodulation training, include those outlined by the APA’s 2001 Task Force Report, The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. The report proposes that psychiatry residents should observe at least ten ECT treatments for three different patients and complete four hours of formal didactic education, which covers clinical indications, administration techniques, and management of adverse effects, among other principles (18). Additionally, an International Federation of Clinical Neurophysiology (IFCN) committee has proposed TMS training guidelines, which include core knowledge of TMS theory and mechanisms, basic skills for TMS use, and safety and ethical concerns (19). Additional literature from the IFCN committee has delineated competencies for clinicians who have completed residency training (20). There are also publications on core competencies for an interventional psychiatry fellowship in noninvasive and invasive neuromodulation – including indications, evaluation, and periprocedural care (21). However, there is limited literature, if any, that proposes competencies across neuromodulation modalities during general psychiatry residency.

Training in brain stimulation aligns with the emerging trend of competency-based medical education (CBME) (22). One avenue for implementation could be through entrustable professional activities (EPAs) (23), which are complementary approaches to CBME that involve targeted assessments. High-fidelity simulation may reduce negative attitudes related to ECT (24) and improve skills and knowledge (25). Psychiatry residents participating in a blended ECT curriculum for late-life depression, including clinical cases, didactic seminars, and hands-on management, expressed high satisfaction (26). Institutions have explored the value of disseminating self-learning modules (SLM) on TMS for treatment-resistant depression, and found that SLMs could serve as effective primers for trainees prior to hands-on training (27). Finally, the modified Delphi process could be utilized to develop consensus in postgraduate ECT and TMS competencies (28, 29).

Ultimately, the approach outlined in this article aims to contribute to the development of a well-rounded and competent generation of future psychiatrists equipped to navigate the complexities of modern neuromodulation techniques in psychiatry.

2 Electroconvulsive therapy 2.1 Status in clinical psychiatry training programs

Estimates of ECT exposure in psychiatry residency vary, but studies have shown that 75% of residency programs require ECT exposure, though 37% stated that a resident would participate in less than ten treatments (30). Prior work has suggested that insufficient training may prevent psychiatrists from practicing effective medical care, which can reduce patient access to life-altering treatments, including ECT (31).

2.2 Current FDA status

ECT is FDA-cleared for severe major unipolar or bipolar depressive episodes and catatonia, for those that are 13 years or older, and whose disorder is “treatment resistant, or requiring rapid response due to the severity of their psychiatric or medical condition (32).” In 2018, the FDA reclassified ECT devices from Class III (high risk) to Class II (moderate risk) (32). Estimates of ECT use vary, but one study evaluating insurance claims found that the ECT utilization rate was 5.56 per 100,000 patients in the general population (33).

2.3 Recommended core knowledge 2.3.1 Mechanisms of action

Residents should know that ECT induces controlled seizures by delivering electrical currents to the brain, leading to alterations in neurotransmitter release and synaptic plasticity (34).

2.3.2 Clinical indications and contraindications

ECT is FDA-cleared for severe major depression in unipolar or bipolar disorder (35), and for catatonia. Off-label indications include acute schizophrenia episodes, bipolar manic and mixed episodes. There are no absolute contraindications to ECT, but relative contraindications include unstable medical conditions, active chest infection, recent myocardial infarction, and high intracranial pressure (36).

2.3.3 Adverse effects

Trainees should know ECT’s common adverse effects, including cognitive impairment, headaches, cardiovascular complications, increased intracranial pressure, and muscle soreness (37). However, advancements in ECT technique, such as ultra-brief pulse stimuli, have reduced cognitive side effects.

2.3.4 Informed consent

Psychiatrists should understand how to provide patients with comprehensive information about the procedure, its potential benefits, and risks. Psychiatrists in the United States should know that guidelines regarding voluntary and involuntary ECT vary depending on the state of practice. Informed consent for ECT is preferable. However, patients with catatonia or severe behavioral disorders are often unable to provide informed consent, and these cases should be considered in accordance with state-specific guidelines for involuntary ECT.

2.3.5 Dosing considerations

Dosing parameters for ECT, including stimulus intensity, frequency, pulse width and train duration, are individualized. General psychiatrists should know that ECT dosage is set relative to the threshold for inducing seizure, and titrating seizure threshold allows for precise dosing, minimizing adverse effects while optimizing therapeutic outcomes. An ECT curriculum should also cover the different types of ECT based on electrode placement (i.e., bifrontal, unilateral, bitemporal), pulse width and dosage relative to seizure threshold. A typical acute treatment course is 2 or 3 treatment sessions per week, over 4 weeks. Continuation ECT can occur with a taper to weekly or monthly sessions over six months, after which maintenance ECT is typically provided every 1–12 weeks (38).

2.3.6 Clinical management

Close collaboration between the referring psychiatrist and the ECT team is essential for proper psychopharmacological management before, during and after ECT. Continuation and maintenance ECT, along with combination pharmacotherapy, may help maintain remission after the acute course of ECT. For involuntary ECT, regular communication with the patient’s family or surrogate decision-maker is essential.

3 Transcranial magnetic stimulation 3.1 Status in clinical psychiatry training programs

The presence of TMS education in psychiatry residency varies, and there is limited research that indicates whether TMS is included in the core educational curriculum.

3.2 Current FDA status

TMS gained its first FDA-clearance for depression in 2008 (39). TMS is currently FDA-cleared for the treatment of major depressive disorder, obsessive-compulsive disorder, migraines, smoking cessation, and anxious depression, all in adults (40). Recently, a group of TMS experts in Europe have established clinical recommendations for repetitive TMS (rTMS) protocols (41), and a group in Portugal provided an overview of the regulatory landscape for TMS (42), both of which could inform residency curriculum.

3.3 Recommended core knowledge 3.3.1 Mechanisms of action

TMS exerts its therapeutic effects by generating magnetic fields that induce electrical currents in specific brain regions. This stimulation modulates neuronal activity, leading to changes in neurotransmitter release and synaptic plasticity (43).

3.3.2 Clinical indications and contraindications

TMS is commonly used for treatment-resistant depression, after the lack of response to at least one antidepressant medication. Its applications also include the FDA-cleared conditions listed above. Relative contraindications may include the presence of metal implants in the head, a history of seizures, or head trauma (19).

3.3.3 Adverse effects

TMS is generally well-tolerated, with few systemic side effects. Common adverse effects include mild scalp discomfort or headache during or after the procedure. Seizures are a rare adverse event (44).

3.3.4 Informed consent

Informed consent for TMS involves providing patients with information about the procedure, its potential benefits, and possible side effects. Patients should understand the non-invasiveness of TMS, the duration and frequency of sessions, the low risk of systemic side effects and the expected outcomes.

3.3.5 Dosing considerations

TMS dosing involves specifying the stimulation parameters, including identifying a patient’s motor threshold, defining the form of TMS (i.e. monofrequency versus intermittent theta burst (iTBS), its stimulation schedule (i.e. daily versus accelerated protocols), and specifying the type of TMS coil (H-coil versus the figure-8 coil). The general psychiatrist should know that TMS pulse intensity is set relative to the threshold to induce a motor twitch. Failing to titrate motor threshold could lead to a seizure (for excessively high doses) or inadequate treatment (for inappropriately low doses). FDA-cleared protocols specify dosing, coil type, and stimulation schedule. Most TMS treatment schedules are daily sessions over 4–6 weeks (45), but accelerated protocols involve up to ten sessions daily over 5 days (46).

3.3.6 Clinical management

Collaboration between the referring psychiatrist and the TMS care team is vital for effective clinical management. Monitoring treatment response, adjusting stimulation parameters as needed, and addressing any side effects contribute to the success of TMS therapy. Psychiatrists may also consider pairing TMS with psychotherapy, which may benefit certain patients (47). Relapse prevention strategies, such as continued TMS and combination pharmacotherapy, can sustain remission.

4 Deep brain stimulation 4.1 Status in clinical psychiatry training programs

Exposure to DBS in psychiatry residency training has not been quantified in the literature to our knowledge. However, one may expect that exposure to DBS is less than that to ECT and TMS due to the invasive nature of the treatment. DBS is reserved for cases with significant treatment resistance, which may also contribute to a limited knowledge base among psychiatrists. DBS management requires specialized interventional units to facilitate collaboration between neurosurgeons, psychiatrists, and nursing staff.

One survey of psychiatrists and psychiatry residents in North America suggested practitioners were more likely to refer patients for DBS as a therapeutic option over other forms of functional neurosurgery; however, the number of referrals remains very low due to the group citing a lack of procedural knowledge and safety concerns (48).

4.2 FDA clearance status

At the time of this writing, in psychiatry, DBS has only received FDA clearance for treatment-resistant obsessive-compulsive disorder under the Humanitarian Device Exemption (HDE H050003) in 2009 (49).

4.3 Recommended core knowledge 4.3.1 Mechanisms of action

DBS involves neurosurgical implantation of electrodes that deliver electricity to targeted regions of the brain to modulate neural circuits. DBS induces changes in neurotransmitter systems and can modulate neural pathways associated with psychiatric symptoms. DBS may suppress pathological neural circuits or facilitate the development of new synaptic connections (50).

4.3.2 Clinical indications and contraindications

Treatment resistant obsessive-compulsive disorder is currently the only FDA-cleared psychiatric treatment of DBS. Contraindications include medical comorbidities that would make a patient a poor surgical candidate, in addition to substance use, personality disorders, cognitive impairment, and brain pathology that would interfere with the effectiveness of DBS (i.e tumor, stroke, cerebral atrophy) (51).

4.3.3 Adverse effects

Similar to other neurosurgical interventions, potential adverse effects of DBS include surgical complications, headaches, fatigue, and mood fluctuations (52).

4.3.4 Informed consent

Obtaining informed consent for DBS is a nuanced process, which should involve consultation with DBS experts and the neurosurgeon in an interdisciplinary manner.

4.3.5 Dosing considerations

Psychiatry residents should be aware that individualized dosing is a critical aspect of DBS therapy. Adjustments can be made to the frequency, intensity, pulse width and location of stimulation. Titration of dose is usually made over 3 to 6 months based on the clinical response (53). DBS dosing should be managed by DBS experts and general psychiatrists should plan to have regular communication with the DBS team to optimize clinical outcomes.

4.3.6 Clinical management

DBS candidates already have a high degree of symptom severity and chronicity. Optimal collaboration requires that psychiatrists recognize both symptom improvement and adverse effects, and that neurosurgeons are equipped to make relevant surgical decisions. Due to the invasiveness and interdisciplinary nature of the procedure, trainees should know when to appropriately refer for DBS. Long-term care requires vigilance for signs of relapse (that might signal the need for parameter adjustment or battery replacement) and optimizing pharmacological and behavioral interventions to maximize functioning.

5 Vagus nerve stimulation 5.1 Status in clinical psychiatry training programs

To the best of our knowledge, there is limited emphasis on VNS training, if any, in psychiatry residency training programs. Furthermore, literature suggests that psychiatrists lack adequate exposure to VNS as a form of therapy, possibly due to its limited use (54).

5.2 FDA clearance status

VNS was FDA-cleared for the treatment of epilepsy in 1997 (55), and for treatment-resistant depression in 2005 (56). VNS is on-label for adults with chronic or recurrent illness (defined as ≥2 years) who are treatment resistant (defined as not responding to ≥4 adequate medication trials) as an adjunctive treatment (e.g. add-on to medications).

5.3 Recommended core knowledge 5.3.1 Mechanisms of action

VNS involves surgical implantation of the VNS device on the chest under the left collarbone and surgical access in the neck to the left vagus nerve where electrodes connect to the generator in the chest. The electrodes deliver stimulation to the vagus nerve, which modulates neurotransmitters and induces neuroplastic changes (57).

5.3.2 Clinical indications and contraindications

VNS is FDA-cleared for the adjunctive long-term treatment of chronic treatment resistant unipolar and bipolar depression. Relative contraindications include poor surgical candidates, prior resection of the vagus nerve, personality disorders, substance use, severe arrythmias, history of vasovagal syncope, history of asthma or obstructive sleep apnea, hoarseness, or gastric or duodenal ulcer (58).

5.3.3 Adverse effects

During stimulation, adverse effects include hoarseness and voice alteration. Dyspnea, cough and neck discomfort are also possible side effects. Transient laryngo-tracheal dysfunction, associated with stimulation of the recurrent laryngeal nerve, occurs transiently in 66% of cases (59). True vocal cord paralysis occurs transiently in 1–2.7% of cases (59). Implantation of the device has a potential for surgical complications, including infection and hemorrhage (60).

5.3.4 Informed consent

Psychiatrists should know that informed consent for VNS is a multidisciplinary process involving VNS experts and neurosurgeons. Patients should understand the implications of having an implanted device, which includes regular monitoring and modifications to device parameters.

5.3.5 Dosing considerations

VNS stimulation parameters include pulse width, current intensity, frequency, on-off time, and duration. Parameters are individualized based on the clinical response (61). General psychiatrists should work closely with VNS experts in each case.

5.3.6 Clinical management

VNS is traditionally considered a long-term approach to treating depression (62), so psychiatrists should evaluate whether they can ensure continuity in potential VNS candidates. Similarly to DBS, regular monitoring of stimulation parameters and addressing adverse effects is important. It is also important to remember to turn the VNS off should the patient need ECT, because it is an anticonvulsant.

6 Next generation neuromodulation

This manuscript focuses on currently FDA-cleared neuromodulation technologies, but this is a rapidly evolving field. Experimental noninvasive brain stimulation (NIBS) therapies include MST, transcranial electrical stimulation (tES) [e.g., tDCS, transcranial alternating electrical current stimulation (tACS)], transcutaneous VNS (tVNS), cranial electrotherapy stimulation (CES), low intensity focused ultrasound (LIFU), temporal interference stimulation, transcranial photobiomodulation, and pulsed electromagnetic field therapy. At this time, these techniques require further investigation for use in psychiatry.

Adequate training of psychiatry residents in neuromodulation prepares them to review literature to stay abreast of new developments and make evidence-based recommendations to their patients. This includes future FDA-cleared devices and the latest guidance on expanded clinical indications and optimization of dosing parameters for currently approved devices.

7 Conclusion

In summary, as the field of neuromodulation develops, training psychiatry residents in the appropriate use of techniques like ECT, TMS, DBS, and VNS should be an essential part of residency curriculum. Improving neuromodulation education may increase patient access to these therapeutic approaches in the future. Whether or not a psychiatrist chooses to specialize in delivering neuromodulation therapies, it is incumbent on all psychiatrists to identify patients who should be referred to neuromodulation therapies, and to provide comprehensive patient care during and after clinical neuromodulation interventions to optimize outcomes and prevent relapse.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Author contributions

SM: Conceptualization, Writing – original draft, Writing – review & editing. TT: Conceptualization, Supervision, Writing – review & editing. BL: Supervision, Writing – review & editing. BG: Writing – review & editing. LC: Supervision, Writing – review & editing. WR: Conceptualization, Supervision, Writing – review & editing. SL: Conceptualization, Supervision, Writing – review & editing.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was supported by ZIAMH002955.

Conflict of interest

SL is inventor on patents and patent applications on electrical and magnetic brain stimulation therapy systems held by the NIH and Columbia University, with no remuneration.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Author disclaimer

The opinions expressed in this article are the author’s own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States government.

References 1 Program Requirements and FAQs and Applications . Available online at: https://www.acgme.org/specialties/psychiatry/program-requirements-and-faqs-and-applications/ (Accessed January 19, 2024). 2 Williams

Taylor

Kerns

Short

Kantor

George

. Interventional psychiatry: why now? J Clin Psychiatry. (2014) 75:895–7. doi: 10.4088/JCP.13l08745 3 Nikayin

Taylor

Ostroff

. Advanced training in interventional psychiatry. J Neurol Sci. (2022) 434:120093. doi: 10.1016/j.jns.2021.120093 4 Association

. Practice guideline for the treatment of patients with major depressive disorder (third edition). American Psychiatric Association. Am J Psychiatry. (2010) 167:1 5 Milev

Giacobbe

Kennedy

Blumberger

Daskalakis

Downar

. Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatry. (2016) 61:561–75. doi: 10.1177/0706743716660033 6 Cabrera

Miller

MMC

Achtyes

McCright

Bluhm

. Jumping through the hoops: Barriers and other ethical concerns regarding the use of psychiatric electroceutical interventions. Psychiatry Res. (2022) 313:114612. doi: 10.1016/j.psychres.2022.114612 7 Slade

Jahn

Regenold

Case

. Association of electroconvulsive therapy with psychiatric readmissions in US hospitals. JAMA Psychiatry. (2017) 74:798–804. doi: 10.1001/jamapsychiatry.2017.1378 8 Case

Bertollo

Laska

Siegel

Wanderling

Olfson

. Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression. J Affect Disord. (2012) 136:359–65. doi: 10.1016/j.jad.2011.11.026 9 Noorani

Rohde

Feuer

Lisanby

Regenold

. Electroconvulsive therapy in the United States: A 2022 survey of practice. J ECT. (2023) 10-1097. doi: 10.1097/YCT.0000000000000991 10 Black Parker

McCall

Spearman-McCarthy

Rosenquist

Cortese

. Clinicians’ Racial bias contributing to disparities in electroconvulsive therapy for patients from racial-ethnic minority groups. PS. (2021) 72:684–90. doi: 10.1176/appi.ps.202000142 11 FitzGerald

Hurst

. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. (2017) 18:19. doi: 10.1186/s12910–017-0179–8 12 Fani

White

Marshall-Lee

Hampton-Anderson

. Antiracist practice in psychiatry: principles and recommendations. FOC. (2022) 20:270–6. doi: 10.1176/appi.focus.20220045 13 Case

Bertollo

Laska

Price

Siegel

Olfson

. Declining use of electroconvulsive therapy in United States general hospitals. Biol Psychiatry. (2013) 73:119–26. doi: 10.1016/j.biopsych.2012.09.005 14 Wilkinson

Kitay

Harper

Rhee

Sint

Ghosh

. Barriers to the implementation of electroconvulsive therapy (ECT): results from a nationwide survey of ECT practitioners. PS. (2021) 72:752–7. doi: 10.1176/appi.ps.202000387 15 Gazdag

Sebestyén

Ungvari

Tolna

. Impact on psychiatric interns of watching live electroconvulsive treatment. Acad Psychiatry. (2009) 33:152–6. doi: 10.1176/appi.ap.33.2.152 16 Stern

Boes

Haller

Bloomingdale

Pascual-Leone

Press

. Psychiatrists’ Attitudes toward transcranial magnetic stimulation. Biol Psychiatry. (2016) 80:e55–6. doi: 10.1016/j.biopsych.2015.07.027 17 Horvath

Perez

Forrow

Fregni

Pascual-Leone

. Transcranial magnetic stimulation: a historical evaluation and future prognosis of therapeutically relevant ethical concerns. J Med Ethics. (2011) 37:137–43. doi: 10.1136/jme.2010.039966 18 American Psychiatric Association . The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (A Task Force Report of the American Psychiatric Association). United States: American Psychiatric Pub (2008). 364 p 19 Rossi

Antal

Bestmann

Bikson

Brewer

Brockmöller

. Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clin Neurophysiol. (2021) 132:269–306. doi: 10.1016/j.clinph.2020.10.003 20 Fried

Santarnecchi

Antal

Bartres-Faz

Bestmann

Carpenter

. Training in the practice of noninvasive brain stimulation: Recommendations from an IFCN committee. Clin Neurophysiol. (2021) 132:819–37. doi: 10.1016/j.clinph.2020.11.018 21 Trapp

Williams

. The future of training and practice in neuromodulation: an interventional psychiatry perspective. Front Psychiatry. (2021) 12:734487. doi: 10.3389/fpsyt.2021.734487 22 Danilewitz

Ainsworth

Liu

Vila-Rodriguez

. Towards competency-based medical education in neurostimulation. Acad Psychiatry. (2020) 44:775–8. doi: 10.1007/s40596–020-01195-z 23 Hung

Jibson

Sadhu

Stewart

Walker

Wichser

. Wresting with implementation: a step-by-step guide to implementing entrustable professional activities (EPAs) in psychiatry residency programs. Acad Psychiatry. (2021) 45:210–6. doi: 10.1007/s40596–020-01341–7 24 Daaboul

Fovet

Nunes

Lebuffe

Vaiva

Amad

. High-fidelity simulation: A promising tool to tackle negative representations of electroconvulsive therapy in psychiatry residents. J ECT. (2021) 37:e32. doi: 10.1097/YCT.0000000000000774 25 Raysin

Gillett

Carmody

Goel

McAfee

Jacob

. From information to simulation: improving competency in ECT training using high-fidelity simulation. Acad Psychiatry. (2018) 42:653–8. doi: 10.1007/s40596–017-0859–1 26 Owais

Saperson

Levinson

Payne

Lamont

Brown

. Evaluation of the online component of a blended learning electroconvulsive therapy curriculum for psychiatry residents to treat depression in older adults. Acad Psychiatry. (2023) 48(1):36–40. doi: 10.1007/s40596–023-01825–2 27 Wang

Nelson

. Transcranial magnetic stimulation for treatment-resistant depression: an interactive self-learning module. MedEdPORTAL. (2018) 14:10713. doi: 10.15766/mep_2374–8265.10713 28 Al-Qadhi

Chawla

Seabrook

Campbell

Burhan

. Competency by design for electroconvulsive therapy in psychiatry postgraduate training: face and content validation study. J ECT. (2020) 36:18. doi: 10.1097/YCT.0000000000000646 29 Lai

KSP

Waxman

Blumberger

Giacobbe

Hasey

McMurray

. Competencies for repetitive transcranial magnetic stimulation in postgraduate medical education: expert consensus using a modified delphi process. Can J Psychiatry. (2023) 68:916–24. doi: 10.1177/07067437231164571 30 Dinwiddie

Spitz

. Resident education in electroconvulsive therapy. J ECT. (2010) 26:310. doi: 10.1097/YCT.0b013e3181cb5f78 31 Lamberg

. Interest surging in electroconvulsive and other brain stimulation therapies. JAMA. (2007) 298:1147–9. doi: 10.1001/jama.298.10.1147 32 Neurological Devices; Reclassification of Electroconvulsive Therapy Devices; Effective Date of Requirement for Premarket Approval for Electroconvulsive Therapy Devices for Certain Specified Intended Uses (2018). Federal Register. Available online at: https://www.federalregister.gov/documents/2018/12/26/2018–27809/neurological-devices-reclassification-of-electroconvulsive-therapy-devices-effective-date-of (Accessed February 3, 2024). 33 Wilkinson

Agbese

Leslie

Rosenheck

. Identifying recipients of electroconvulsive therapy: data from privately insured Americans. PS. (2018) 69:542–8. doi: 10.1176/appi.ps.201700364 34 Merkl

Heuser

Bajbouj

. Antidepressant electroconvulsive therapy: Mechanism of action, recent advances and limitations. Exp Neurol. (2009) 219:20–6. doi: 10.1016/j.expneurol.2009.04.027 35 Weiner

Reti

. Key updates in the clinical application of electroconvulsive therapy. Int Rev Psychiatry. (2017) 29:54–62. doi: 10.1080/09540261.2017.1309362 36 Parker

Hunt

. Electroconvulsive therapy: A review. Brown Univ Child Adolesc Behav Lett. (2019) 35:1–6. doi: 10.1002/cbl.30390 37 Andrade

Arumugham

Thirthalli

. Adverse effects of electroconvulsive therapy. Psychiatr Clinics. (2016) 39:513–30. doi: 10.1016/j.psc.2016.04.004 38 Thirthalli

Sinha

Sreeraj

. Clinical practice guidelines for the use of electroconvulsive therapy. Indian J Psychiatry. (2023) 65:258. doi: 10.4103/Indianjpsychiatry.Indianjpsychiatry_491_22 39 Yan

. FDA approves new option to treat major depression. Psychiatr News. (2008) 43(22):2. doi: 10.1176/pn.43.22.0002 40 Cohen

Bikson

Badran

George

. A visual and narrative timeline of US FDA milestones for Transcranial Magnetic Stimulation (TMS) devices. Brain Stimul. (2022) 15:73–5. doi: 10.1016/j.brs.2021.11.010 41 Lefaucheur

J-P

Aleman

Baeken

Benninger

Brunelin

Di Lazzaro

. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014–2018). Clin Neurophysiol. (2020) 131:474–528. doi: 10.1016/j.clinph.2019.11.002 42 Cotovio

Ventura

Rodrigues da Silva

Pereira

Oliveira-Maia

. Regulatory clearance and approval of therapeutic protocols of transcranial magnetic stimulation for psychiatric disorders. Brain Sci. (2023) 13:1029. doi: 10.3390/brainsci13071029 43 Jannati

Oberman

Rotenberg

Pascual-Leone

. Assessing the mechanisms of brain plasticity by transcranial magnetic stimulation. Neuropsychopharmacol. (2023) 48:191–208. doi: 10.1038/s41386–022-01453–8 44 Taylor

Newberger

Stern

Phillips

Feifel

Betensky

. Seizure risk with repetitive TMS: Survey results from over a half-million treatment sessions. Brain Stimulation. (2021) 14:965–73. doi: 10.1016/j.brs.2021.05.012 45 Perera

George

Grammer

Janicak

Pascual-Leone

Wirecki

. The clinical TMS society consensus review and treatment recommendations for TMS therapy for major depressive disorder. Brain Stimulation. (2016) 9:336–46. doi: 10.1016/j.brs.2016.03.010 46 van Rooij

SJH

Arulpragasam

McDonald

Philip

. Accelerated TMS - moving quickly into the future of depression treatment. Neuropsychopharmacol. (2024) 49:128–37. doi: 10.1038/s41386–023-01599-z 47 Sathappan

Luber

Lisanby

. The Dynamic Duo: Combining noninvasive brain stimulation with cognitive interventions. Prog Neuropsychopharmacol Biol Psychiatry. (2019) 89:347–60. doi: 10.1016/j.pnpbp.2018.10.006 48 Cormier

Iorio-Morin

Mathieu

Ducharme

. Psychiatric neurosurgery: A survey on the perceptions of psychiatrists and residents. Can J Neurol Sci. (2019) 46:303–10. doi: 10.1017/cjn.2019.5 49 Humanitarian Device Exemption (HDE) . Available online at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfhde/hde.cfm?id=375533 (Accessed February 5, 2024) 50 Udupa

Chen

. The mechanisms of action of deep brain stimulation and ideas for the future development. Prog Neurobiol. (2015) 133:27–49. doi: 10.1016/j.pneurobio.2015.08.001 51 Polosan

Leentjens

AFG

. Deep brain stimulation in obsessive-compulsive disorder. In: Temel

Leentjens

AFG

de Bie

RMA

Chabardes

Fasano

, editors. Fundamentals and Clinics of Deep Brain Stimulation: An Interdisciplinary Approach. Springer International Publishing, Cham (2020). p. 263–78. doi: 10.1007/978–3-030–36346-8_17 52 Zarzycki

Domitrz

. Stimulation-induced side effects after deep brain stimulation – a systematic review. Acta Neuropsychiatrica. (2020) 32:57–64. doi: 10.1017/neu.2019.35 53 Ramasubbu

Lang

Kiss

ZHT

. Dosing of electrical parameters in deep brain stimulation (DBS) for intractable depression: A review of clinical studies. Front Psychiatry. (2018) 9:302. doi: 10.3389/fpsyt.2018.00302 54 Heyman-Kantor

Cockerill

. Ethical issues in vagus nerve stimulation and deep brain stimulation. FOC. (2022) 20:71–5. doi: 10.1176/appi.focus.20210031 55 Premarket Approval (PMA) . Available online at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P970003 (Accessed April 22, 2024) 56 Premarket Approval (PMA) . Available online at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=p970003s050 (Accessed April 22, 2024) 57 Nemeroff

Mayberg

Krahl

McNamara

Frazer

Henry

. VNS therapy in treatment-resistant depression: clinical evidence and putative neurobiological mechanisms. Neuropsychopharmacol. (2006) 31:1345–55. doi: 10.1038/sj.npp.1301082 58 Toffa

Touma

El Meskine

Bouthillier

Nguyen

. Learnings from 30 years of reported efficacy and safety of vagus nerve stimulation (VNS) for epilepsy treatment: A critical review. Seizure. (2020) 83:104–23. doi: 10.1016/j.seizure.2020.09.027 59 Giordano

Zicca

Barba

Guerrini

Genitori

. Vagus nerve stimulation: Surgical technique of implantation and revision and related morbidity. Epilepsia. (2017) 58:85–90. doi: 10.1111/epi.13678 60 Kahlow

Olivecrona

. Complications of vagal nerve stimulation for drug-resistant epilepsy: A single center longitudinal study of 143 patients. Seizure. (2013) 22:827–33. doi: 10.1016/j.seizure.2013.06.011 61 Thompson

O’Leary

Austelle

Gruber

Kahn

Manett

. A review of parameter settings for invasive and non-invasive vagus nerve stimulation (VNS) applied in neurological and psychiatric disorders. Front Neurosci. (2021) 15:709436. doi: 10.3389/fnins.2021.709436 62 Rush

Sackeim

Marangell

George

Brannan

Davis

. Effects of 12 months of vagus nerve stimulation in treatment-resistant depression: A naturalistic study. Biol Psychiatry. (2005) 58:355–63. doi: 10.1016/j.biopsych.2005.05.024